When Taylor-Rey J’Vera became pregnant with their first child in 2021, they wanted to choose their OB-GYN carefully. “I searched for someone brown and female-bodied, because I thought that would make me feel safer and healthier,” said J’Vera, who identifies as a Black and Puerto Rican plus-sized, non-binary lesbian.
Instead, their first-ever appointment became a traumatizing experience. The doctor said J’Vera’s weight made them high risk, despite their normal blood pressure and bloodwork. She asked them repeatedly if they wanted to “keep the baby”. And when she realized J’Vera was a lesbian, she made a statement comparing artificial insemination to cheating.
Even so, J’Vera balked when their wife suggested a new maternity clinic called Oula, where the primary practitioners are midwives. “When I thought of midwifery, I thought of people sitting in a ‘kumbaya’ circle while ladies are screaming their head off,” J’Vera said.
Oula quickly dispelled this notion. J’Vera was impressed with the office’s “Gwyneth Paltrow vibe” – buttery-soft textiles in beige, cream and muted pink – but also the sense of welcome; at J’Vera’s first appointment, the midwife gave her pronouns and asked J’Vera for theirs.
In October 2021, J’Vera gave birth to a son, River, after an induction and caesarean. It wasn’t the birthing experience they’d hoped for, but that was less important to J’Vera than their experience of pregnancy as a whole. They weren’t constantly put on a scale. Their medical questions were promptly answered through Oula’s app. They “felt safe and taken care of” throughout. “Not just my body,” J’Vera said. “My heart and my mind.”
Oula has raised $22.3m in venture capital on the promise of its midwife-centered, technology-integrated approach to “modern maternity” care. Its ethos is collaborative, meaning appointments are run by certified nurse midwives at Oula’s offices, while all births take place at the hospital. Two staff obstetrician gynecologists are available to oversee high-risk pregnancies.
The company says its user-friendly app provides patients more control over the maternity experience and its proprietary software increases safety and efficiency. It maintains this modernized approach is compatible with what many midwives call their “sacred practice”: prenatal appointments that emphasize holistic, compassionate care and a low-intervention approach to labor and birth.
Patients like J’Vera are having a better experience than they might at a traditional doctor’s office. But there’s still healthy skepticism, especially from midwives, about this influx of money: is the need – and desire – to scale these businesses really compatible with a slow, relationship-centered approach to maternity care? And do these companies fully understand the challenges of building effective midwifery practices in hospitals, especially when it comes to the most vulnerable patients?
Midwifery is having a moment in the US: Oula is one of at least four venture capital-funded midwifery startups that have launched since 2019. Silicon Valley, with its deep pockets, technological savvy and growth mindset, is bidding to be the disrupting force our country’s maternity care desperately needs.
Numerous studies show that midwifery reduces healthcare costs and improves the quality of care and outcomes, especially for vulnerable patients. And yet unlike other developed countries like the UK and Germany, where midwives assist most low-risk pregnancies, the practice is an outlier in the US. There are only 14,000 certified nurse midwives and certified midwives in the US, compared with more than 21,000 OB-GYNs.
Those numbers are slowly changing. According to the American College of Nurse-Midwives (ACNM), the number of midwifery education programs increased to 46, up from 38 last year, and the number of midwifery students is growing. Ginger Breedlove, a former president of the ACNM, says that interest in midwifery is “exploding”.
There are plenty of reasons for this shift. First, people recognize that maternity care is broken: the US has high rates of maternal morbidity among developed countries, and terrible outcomes for Bipoc patients. We have a 32% general cesarean rate, compared with the World Health Organization’s recommendation of 10 to 15%. Maternity care “deserts” now force families to drive hours to see a doctor.
Second, midwives achieve similar or better outcomes than obstetricians do when caring for low-risk patients, though they’re paid half as much. One 2019 study of more than 23,000 hospital births in low-risk patients found that midwifery care in labor had “significantly lower” cesarean rates than obstetrician-led care, while a 2018 study found that states with more midwives integrated into their health systems had lower rates of cesarean births, pre-term births, low birth weight babies and neonatal death.
Third, systemic changes are slowly working in midwives’ favor. The Affordable Care Act requires Medicaid to cover midwifery services, though providers can be hard to find. And private insurers are testing a global fee model for maternity care, under which the entirety of pregnancy and birth falls under one cost. Even so, most hospitals still work on a “fee-for-service” reimbursement model, in which providers get paid for each visit and procedure.
Anu Sharma, who has raised over $4m in venture capital for Millie, her California-based maternity care startup, says that historically there’s been a “built-in bias with more procedures than necessary”, because proceduralized care equates to higher reimbursement.
Sharma also noted that obstetricians are trained surgeons, and some are biased toward medicalized rather than vaginal deliveries. And there’s the persistent problem of time: too many patients and not enough hours in the day. Cesareans “spike at 7am and noon, because that’s when doctors need babies to be born to manage their day”, said Kate Condliffe, CEO of Diana Health, another startup that has raised $64m.
Finally, many states have changed their licensing requirements to allow midwives to practice independently, without the formal oversight or supervision of a physician. But most midwives must still get a physician to sign off to practice in a hospital.
Karen Jefferson, the director of midwifery practice and education at the ACNM, wishes “that every hospital with maternity services would offer midwifery care the way they offer neurology, pediatrics or dermatology. Midwives would be complementary to OB-GYNs,” she said. “We make a great team, but that is not the structure that exists in the US.”
Enter the VC-funded startups. They’ve arrived on the scene at a moment when culture and policy are slowly shifting toward midwifery. The women behind these companies want to improve clients’ experiences with maternity care, but their broader mission is systemic change.
“It’s not rocket science what it looks like to deliver better maternity care,” said Adrianne Nickerson, Oula’s co-founder and CEO. “But why hasn’t it scaled? Why is a midwifery model that’s common in the UK and other countries with better outcomes not common here?”
The female founders behind these startups approach this question through a mix of business and public health expertise. Nothing will change, they argue, until you can get paid for producing better health outcomes rather than doing more medical procedures. But to convince insurance companies to change their payment model, you need a lot of evidence; you need to scale – which requires a lot of money upfront. “Investment capital,” Nickerson said, “is how you get beyond the early stages of business to the point where scale unlocks.”
Oula hasn’t released its precise outcomes. For over 1,000 births, the company claims a first-time, low-risk cesarean rate of just over 20%, compared with 26% nationally, according to March of Dimes statistics. Its pre-term delivery rates are under 4%, compared with over 10% nationally. And its success rate for vaginal deliveries after a previous cesarean is over 80%, compared with a national average of between 60% and 80%.
Amanda Segilia, an Oula midwife with 18 years of experience, said the company’s technology has been a boon for both her and her patients. She pointed to the Oula app, which allows people to ask nurse practitioners questions in between appointments and the efficient proprietary software the company built to complement its electronic medical records system. Segilia liked its “Risk Watch” feature, which allows midwives to flag patient cases that require close obstetrician collaboration. “When there’s a problem identified, there’s a team of tech thinkers, a team of business thinkers who are trying to solve those problems,” she said.
Today, Oula has two clinics in New York City, both in the upscale neighborhoods of Brooklyn Heights and Soho. It will open a third location next fall near Columbia University. About 15% of its clients are on Medicaid, just over half identify as people of color and 10% as LGBTQ+. It contracts with Mount Sinai hospital in New York City. But it plans to expand into other markets and health systems next year. It recently added gynecological services for existing patients, and will soon expand into mental health.
To scale further, though, Oula needs to fix midwifery’s branding problem. According to Oula’s research, many Americans conflate midwives with doulas – a person without obstetrics training who supports a pregnant person through labor and delivery. Generally, focus groups thought midwifery sounded “medieval or didn’t sound medical. Sounded risky. Didn’t sound credible,” said Joanne Schneider DeMeireles, Oula’s chief experience officer.
“We’re making midwifery care feel accessible,” Nickerson said. “The pretty clinic, social media marketing, modern technology – this feels like what healthcare should look like. We get the people who weren’t going to get a midwife. That’s why we’ll be successful.”
Still, many people who work in reproductive rights aren’t convinced these startups will be able to prioritize their patients – especially the most vulnerable ones – over the demands and requirements of their investors. Some critics argue that families deserve well-funded maternity care outside the hospital. Others doubt these founders grasp the profound cultural shift that hospitals must make to genuinely embrace midwifery.
Three of the four VC-backed companies only do hospital-based births. (Quilted Health patients have the option to deliver at a hospital in Spokane, Washington, or the company can refer them to deliver in a birth center or at home with a community midwife partner.) Consequently, midwifery’s rebrand – and the money behind it – largely directs patients to a single kind of birth setting.
“We see that as a dilution of the midwifery model of care, which is fundamentally about choice,” said Tenesha Duncan, whose firm, Orchid Capital Collective, is helping to build “community-owned and -driven” solutions to birth and reproductive care. “Especially for Black and Indigenous people, the worst outcomes are happening inside of hospital settings,” Duncan said.
Birth centers, for instance, are shown to produce better outcomes than hospitals for low-risk patients. And they are often staffed by certified professional midwives, who are thoroughly trained, but, unlike certified nurse midwives and certified midwives, are not generally credentialed for hospital-based births.
There is particular interest in birth centers among Black patients because many distrust the medical system due to historical racism within it, and because until the early 20th century, the majority of midwives were Black and did not work in hospitals. Today, just 7% of midwives are Black. Only 20 birthing centers in the country are run by midwives who identify as Bipoc. “Black maternal mortality and infant mortality has become sexy to talk about, but not as sexy to invest in,” said Alicia Bonaparte, a medical sociologist at Pitzer College.
Hospitals aren’t inherently bad, of course, but changing hospital culture also is extremely difficult. “It’s a game of thrones,” said Helena Grant, president of the New York State Association of Licensed Midwives. Grant is the immediate past midwifery director at Woodhull, a public hospital in Brooklyn where midwives run the show. Woodhull mainly serves low-income, Bipoc New Yorkers – those who are most vulnerable to what Grant calls the “medical technocratic patriarchal model of medicine”. In 2021, Woodhull’s cesarean rate for first-time pregnancies was 11%, far lower than Oula’s.
Grant came to Woodhull 17 years ago and helped build its midwifery practice. She said it took decades of sweat and strategy to shift “the mindset and culture among physicians and nursing staff and higher-level hospital administrators”. She listed a series of questions for anyone practicing midwifery in hospitals: were patients with normal-sized babies pressured to be induced at 39 weeks? Were they allowed to eat during labor? Were they given cordless monitors so they could move freely? Were the midwives being “hounded to break someone’s water”?
In short, when push came to push, was the collaborative care model truly that?
“If we’re making it pretty but not ensuring that when a woman goes into labor nobody will sneak in to break her water or pressure the midwife, [then] we don’t change maternal mortality or morbidity or increase patient satisfaction,” Grant said.
There is, of course, the question of where the midwife stands in all of this. Pregnancy in the US is as political as it is personal, and that’s true of midwifery, whose history is intertwined with legacies of racism and sexism, and whose holistic methods many midwives consider sacrosanct.
Midwives care about data and outcomes, of course. But many also consider their job to be a sacred practice that privileges human connection, holistic care and patient autonomy.
Pregnancy is “a sacred golden time where we have the opportunity to not just save or protect the life of the baby but those people who are becoming parents”, said Rachel Blessington, the owner of Worcester Community Midwifery in Massachusetts. “What happens in that pregnancy and birth and postpartum will influence how [parents] are as adults moving forward and how they’ll be able to parent that child.”
Blessington has been working with Grow Midwives, a midwifery business consultancy, to turn her company into a freestanding birth center. She briefly considered going the VC route, but she saw too many tradeoffs. “Will that compromise our values?” she wondered.
Breedlove – who is now CEO of Grow Midwives – worried about the potential pressure startups might place on their midwives to reach lucrative numbers. “If you can’t achieve volume, you’ll have a hard time keeping your business floating. That speed and volume is the antithesis of midwifery,” she said. “We’re not talking about a machine, but about a human relationship: how many patients are they seeing a day, how many births, how many extra responsibilities related to quality metrics? Are they sales people?”
She may be right: some of the midwives who work for these startups say it’s been difficult to manage the number of births required to meet financial benchmarks.
You might “get these low interventions, low cesarians, on-paper-looking-good outcomes”, said one midwife who wished to remain anonymous to protect her job. “But it’s at the expense of the midwife doing the work … I’m a broken human being when I get home.”
She cautioned the midwives who apply to these startups to know what they’re walking into. It might not always feel sacred – which is OK, as long as they have a voice and can provide the scope of care they’ve been trained to deliver.
Nevertheless, Breedlove is hopeful. “Because someone is finally paying attention,” she said. “I’m glad to see someone thinks there’s opportunity here.”
This article was amended on 8 November 2023. An earlier version referred to “certified professional midwives” where “certified midwives” was meant.